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Expert Review of Gastroenterology & Hepatology Volume 13, 2019 - Issue 10
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DIFFICULT PERORAL ENDOSCOPIC MYOTOMY: DEFINITION AND MANAGEMENT STRATEGIES

Yuyong TanDepartment of Gastroenterology, The Second Xiangya Hospital, Central
South University, Changsha, Hunan, ChinaView further author information
,
Chen LiDepartment of Gastroenterology, The Second Xiangya Hospital, Central
South University, Changsha, Hunan, ChinaView further author information
,
Jin YanDepartment of Gastroenterology, The Second Xiangya Hospital, Central
South University, Changsha, Hunan, ChinaView further author information
,
Limin LongDepartment of Geriatrics, The Second Xiangya Hospital, Central South
University, Changsha, Hunan, ChinaView further author information
,
Jirong HuoDepartment of Gastroenterology, The Second Xiangya Hospital, Central
South University, Changsha, Hunan, ChinaView further author information
&
Deliang LiuDepartment of Gastroenterology, The Second Xiangya Hospital, Central
South University, Changsha, Hunan, ChinaCorrespondencedeliangliu@csu.edu.cn
https://orcid.org/0000-0003-1541-2596View further author information
Pages 933-942 | Received 01 Jun 2019, Accepted 25 Sep 2019, Published online: 09
Oct 2019
 * Cite this article
 * https://doi.org/10.1080/17474124.2019.1674648
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ABSTRACT

Introduction: Peroral endoscopic myotomy (POEM) has been established as an
alternative endoscopic method for the treatment of achalasia, and several
studies have confirmed its relatively long-term efficacy. Although most of the
POEM procedures can be smoothly completed, technical difficulties do arise
during the treatment of some patients, which may lead to prolonged procedure
duration, increased procedure-related complications, or even aborted POEM.

Area covered: In the present review, we provide a comprehensive review of
difficult POEM, focusing on its definition, risk factors, and intraoperative
management strategies. The present review is expected to provide tips for not so
experienced operators who perform POEM.

Expert commentary: Submucosal fibrosis and sigmoid-type esophagus are associated
with difficult POEM. Sometimes, the following may also be associated with
difficult POEM: previous endoscopic or surgical treatments, spastic esophageal
disorders (type III achalasia, distal esophageal spasm, and hypercontractile
esophagus), achalasia with diverticulum or situs inversus. For operators who
begin to perform POEM, I suggest an exclusion of patients with severe submucosal
fibrosis or sigmoid-type esophagus, and begin to perform POEM for these patients
when they have completed at least 50 cases of ‘easy POEM’ and the proposed
management strategies may be helpful.

KEYWORDS:

 * Achalasia
 * endoscopic surgery
 * esophageal motility disorders
 * Peroral endoscopic myotomy
 * technique difficulty

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ARTICLE HIGHLIGHTS



 * Most of the POEM procedure could be smoothly completed, however, difficult
   POEM does occur in several cases.

 * We present a definition of difficult POEM as: difficult POEM is characterized
   by a prolonged procedure time, occurrence of major intraoperative adverse
   events or aborted POEM procedures owing to the morphological or
   pathophysiologic changes of esophagus.

 * Submucosal fibrosis and sigmoid-type esophagus are associated with difficult
   POEM.

 * Patients with the following situations sometimes may also encounter difficult
   POEM: previous endoscopic or surgical treatments, spastic esophagus (type III
   achalasia, distal esophageal spasm, and hypercontractile esophagus),
   achalasia with diverticulum or situs inversus.

 * Most of the technical difficulties experienced during POEM could be managed
   by modifications of the POEM procedure.




DECLARATION OF INTEREST

The authors have no relevant affiliations or financial involvement with any
organization or entity with a financial interest in or financial conflict with
the subject matter or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or options, expert
testimony, grants or patents received or pending, or royalties.


REVIEWER DISCLOSURES

Peer reviewers on this manuscript have no relevant financial or other
relationships to disclose.


ADDITIONAL INFORMATION


FUNDING

This study was funded by Development and Reform Commission of Hunan Province
(no. XFGTZ2014713).


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